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FOR OFFICE USE: .; <br /> APPUCAON7OR SANITATION P>ERN6l7 <br /> ----- - - ----=--------•---- Permit No. ------------------ -- <br /> — —, - %(Complete in Triplicate) <br /> This Date Issued <br /> Permit Expires 1 Year From Date Issued `7� <br /> ----------------------------------------------------- . �_ <br /> Application is hereby made to the San Joaquin Local Health District for' a permit to construct and install the work herein <br /> described. This application is made in compliance with CountyOrdinanceNo. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .--_S-�b ----- ------I 4-------------------- -----------------CENSUS TRACT .------------- --------•- <br /> r [ Phone 3----7Y-��-- <br /> Owner's Name ----�f---2--S---------- - � _ <br /> Address ----- -------------------------------------- City �o/J/r-'eq--------- -------------------------- ----------•-- <br /> Contractor's Name ------ ------.License #:I-- Phone &� _. <br /> s <br /> Installation will serve: Residence QgApartment House❑ Commercial ❑Trailer Court l❑ t <br /> r <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ----------- - ---------------------•---- <br /> Number of living units:. Number of bedrooms ------------Garbage Grinder ---._____-- Lot Size ----._------------------------------------- <br /> Water Supply: Public System and name -------------------------------------------- ---------------------------------------------------------------Private <br /> i Character of soil to a depth of 3 feet: Sand'pg Silt.] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> j Hardpan ❑ `Adobe'B -IFill Material•:_---------- If yes,type :-----------f--------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availab a within 200 feet,J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------------------------- --- Liquid Depth ----------.--------------- kp <br /> Capacity----------------- Type ------------------ Material------- --- o- Compartments --------------_-----'6 <br /> Distance to nearest. Well _ ___-----------------------------,Foundation --. Prop. Line -_----_-_-..._-_--.__S <br /> LEACHING LINE [ ] No, of Lines ------------------------ Length of each line-------------------------- _ Total Length ---_--_.---- <br /> 'D' Box ------- --- Type Filter aterial --------------------Depth Filter M teriai --_----------.---.--•------------•---•-•----V <br /> 'I Distance oto nearest: Well --- -------------__.-- Foundation t------------------- ---- Property Line V) <br /> SEEPAGE PIT [ ] Depth J----------------- Diame er ____------- 4I __. Rock. Filled Yes No <br /> ---�. Number -:----..�-- ------- - ❑ <br /> -� <br /> ` Water Table Depth -- -------- ---------------------.`�•-------.Rock Size--------- ---------------•---- <br /> Distance to nearest: Well -- ------------ ----------------------- -------------------- Prop. Line --------.._---_-..__._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _--_.-_--- ------.-----_ -- Date------------------- --------------1 <br /> 1 j4 <br /> Septic Tank (Specify Requirements) --------------------------------------- ------------------------- -----------4--- --------------. <br /> Disposal Field (Specify Requirements) � _ ............... ----�-- ' ��� A---------- <br /> 1 ---------------------=----------------------------------- 4-----------------=------------------ -------------------------------------- <br /> ----------- ---------- - <br /> )I (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that .the work will�'be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: •''`� ' <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject t orkm Compensation laws of California." F "• <br /> Signed - -------------- -------------------------------- --------•------------. Owner <br /> i <br /> By -------- = - - ------ -- -- --- ------- - ---------- ----- -------------- -Title ----- <br /> 3 (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -_ --- ---------------------------------------------------------- DATE -.__:t 21------------------ <br /> BUILDINGPERMIT ISSUED - -------I---------------------------------------------------------------- -------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------- ---------------------------------------------------•------------------------ --- ------------------------------ ---------------------------------- <br /> _V - - ----------- --------- --- --------- <br /> ------------------------------------ <br /> --- <br /> - <br /> - <br /> Final Inspection by: ---------------------- - ----- Date <br /> SAN JOAQUIIV LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />